Medical Critique Hostages: One Episode to be Thankful For

Okay, I admit it. I've been beating up on the CBS drama Hostages. So-- since it is Thanksgiving and we're to be thankful I'm going to give a shout out to Hostages for one accurate story line.

Then it will be back to a hard medical critique as there is MUCH to discuss in some of the most recent episodes.

In one of the minor plots, the teen daughter is, of course, pregnant. Her father takes her to an OB/GYN to check the status of the pregnancy and stays in the waiting room.

Accurate portrayal #1: Teens presenting for care related to reproductive issues or sexually transmitted diseases are treated as adults in the sense that they don't have to have a parent present to consent for treatment and should be seen privately by the physician.

During the exam, the physician asks her what all the bruising is about. And, the teen girl does have a suspicious bruising pattern.

Accurate portrayal #2: Suspicious bruising patterns are those that:
1. Can't be explained by the history given (I fell down the stairs.)
2. Are located over non-bony prominences. This teen presented with bruising to her upper arm (from being grabbed) and to her back (from cutting out a tracking device.)
3. Are numerous and extensive.

The doctor becomes suspicious and notifies social services.

Accurate portrayal #3: A physician is a mandated reporter under most state statutes to report a suspicion of abuse. They don't have to know beyond a shadow of a doubt that something is happening but if, in good faith, they are concerned by what they see then a report is necessary.

In a few days the teen is approached at school by a county social worker for questioning.This occurs in episode seven.

Accurate portrayal #4: There would definitely be an evaluation of the teen in private-- away from the parents. The social worker also interviewed the brother, who also had a black eye. Alone. In psychiatric situations involving teens the family is generally interviewed together and at some point-- each member is interviewed alone to get what's really going on.

So on this Thanksgiving Day-- thank you Hostages for accurately portraying management of a family when there is concern for abuse.

Now everyone-- have a safe and great holiday. I'll be working the ER and I don't want to see you ;)!!

Author Question: Police Death Notification

In my writing life, I've met some fantastic police officers. My own brother is a county sheriff close to where I live so I use him a lot for questions. I've also gotten to meet many other great police officers and one was very helpful in giving me a detailed SWAT scenario for my most release, Peril.

Darcie sent me some police type questions and I passed them along to Seargent S. Tarr and he provided the following insight.

Darcie asks:

What I learned so far is that if my Main character (Kelley)'s parents' bodies were found along a hiking trail near Glenwood Springs, the Denver Police would visit her house to break the news since Kelley lives in the Denver area.

Sergeant Tarr: Yes, if a person is found to be deceased the next of kin is notified by the jurisdiction that the person's family is located. They would usually send a marked patrol unit and a victim advocate. We call it a death notification. Sometime the coroner will also go if it’s in the same jurisdiction. 

Darcie: That leaves me now with, since at first this appears to be a hiking accident, where would the bodies be? Coroner? 

Sergeant Tarr: It doesn’t matter if it appears to be an accident or not. The coroner would handle the investigation into the cause of death and police in the manner (like a homicide, scene traffic accident, suicide etc..) So it would be a joint investigation regardless. The only time the coroner and law enforcement don’t do an investigation is if it happens in a hospital or in the care of medical staff. So the coroner would take the body and most likely perform an autopsy. Would be very uncommon for them not to. The coroner would then rule on the cause of death ie: natural, suicide, accidental, etc.. 

Darcie: Would there be an autopsy? 

Sergeant Tarr: An autopsy would be performed by the jurisdiction that the death happened. The pathologist could be from Denver. I know for example that the pathologist from Fort Collins comes down to Denver to conduct autopsies. The Arapahoe examiner has also traveled to other coroner's offices to assist. 

Darcie: Would Kelley have to go ID them even though they had drivers licenses etc on them?

Sergeant Tarr: This depends on if a positive ID can be made with the id or not. Like if their face was ripped off, sorry to sound crude. They can also put their fingerprints through AFIS to see if they can get an ID that way also. Sometimes the family has to ID the body if no positive ID can be made. It is usually the last thing done. Once the coroner releases the bodies it would be picked up by a funeral service. They would transport the bodies back to Denver for the funeral arrangements.

Up and Coming

Hello Redwood's Fans!

This week is Thanksgiving week-- so it's time to reflect and think about all those things we are grateful for. It's hard for me to do right now (now that I'm not thankful) but I have to work Thanksgiving Day and, to be honest, am a little (okay, a lot) grumpy about it. So, I thought I'd write a few things I'd be thankful for if YOU did them so I could actually not see patients that day.

1. Drink responsibly. No drinking or driving. Don't even try it. It's just not worth it. Think about KILLING someone else on Thanksgiving. If you're going to get hosed-- lock yourself up in your own house and give someone else the keys.

2. Watch those knives. It's JUST dinner. Don't let stress, family arguments, and poor time management cause the silver to flash and fly. If you're using the ER as a break from your family then perhaps you should not be spending the day with these peeps. Just cut out the negative energy.

3. Your kids are going to get a belly ache. It's probably not their appendix-- it's constipation related to ALL the carbs they stuffed in their gut in a short time frame. Make sure they're drinking water and some stuff with fiber. They actually WILL eat the good stuff (raw fruit and veggies) if they are TRULY hungry and that's what you offer. Don't let them eat out of boredom. Have them play outside.

4. You are sharing germs. No double dipping, please. Stay six feet away if someone is coughing and don't be afraid to look stupid for wearing a surgical mask.

5. New babies (under 60 days old)-- should be sheltered and protected. Don't let everyone in the world come around and kiss their cute little faces. Tell the uncle who hasn't shaved, showered or brushed his teeth in the last ten years that next year you'll offer up the newest member of the family for a slobbery smoocher.

Okay-- that's my top five. I really do just want to sit around and drink cocoa all day.

For you this week!

Tuesday: SWAT officer S. Tarr drops in to answer some writerly police operational questions. I thought his answers were so helpful that they could help writers everywhere.

Thursday: I've been beating up quite a bit on the CBS drama Hostages lately so I'm giving them kudos for one episode and then it will be back to the medical critique because I cannot help myself. So-- just what did they actually do right?

Have a safe and overly joyful Thanksgiving!

Jordyn

Medical Critique: CBS Drama Hostages 2/2

This week, I'm medically analyzing the CBS drama Hostages. In the previous post, that you can find here, I said I'd give them some kudos . . . and I will . . . I promise, but it will come at a later time because I'm having too much fun dissecting this episode.

These posts do have spoilers . . . you have been warned.

Last post I discussed the first three issues I had with the episode and they are as follows:

1. Gunshot wound victims are at high risk of dying from blood loss-- not heart arrhythmias.
2. Physicians don't carry hospital grade defibrillators in their back pockets. Maybe Tom Cruise does but I digress . . .
3. Physicians are generally not comfortable operating a defibrillator. This is generally a nursing function once the physician prescribes the amount of electricity he wants delivered.

Onward we go.

Issue Four: After the husband is "brought back to life" Ellen, played by Toni Collette, goes about diagnosing his problem. Keep in mind she's a cradiothoracic surgeon. Now, she will have gone through a general surgery rotation but her specialty will be everything above the diaphragm.

Her husband has a wound to the left upper quadrant of his abdomen. She sticks her finger into the wound-- perhaps up to the first knuckle and declares, "Your renal vein has been severed." or something relatively close to that.

Wow. Just . . . wow.

Your kidneys lay in your mid-lower back. I like the image here a lot and it comes from the noted website. I think this website is AWESOME. There aren't any gory pictures but it has several photos of drawings similar to this one that shows the anatomy as it lies under the skin drawn with ink.



This is how we think in medicine. We say . . . "The patient was shot here . . . what is underneath or along the tract that could be damaged." And from that we order labs, x-rays and advanced imaging like CT.

In reality, there is no possible way to diagnose a renal vein severing with a finger probe to the front of the abdomen . . . or to the back of the abdomen. This needs advanced imaging techniques. Now, there is some gross (not as in yucky) techniques that could likely lend to the diagnosis of injury somewhere along the GU tract. Blood in the urine. Perhaps urine leaking out of a wound. But to be so specific needs advanced imaging.

http://meded.ucsd.edu/clinicalmed/abdomen.htm

And I can't imagine suturing that vein closed with the patient awake and moving around. Those suckers are small.

I actually do think there would have been a better injury to give this character's husband that would have been more in her skill set and MORE dramatic and that is the tension pneumothorax.

A tension pneumo could easily happen in a gunshot wound to the chest. The lung is hit and leaks air into the chest cavity. If enough air accumulates in the chest it actually pushes or shifts the chest organs (lungs and heart) to the unaffected side (imagine a balloon blowing up in the affected side.)

Treatment for this type of injury is a chest tube and could be fashioned from something from the home and perhaps something from her medical supplies. You'd need a large size tube-- they are big-- think maybe 1/2 the size of a diameter of a garden hose and come in various sizes. Once placed, she could secure it with sutures and place the end in water lower than the patient so air didn't get back into the chest.

To diagnose-- you listen to breath sounds. There are no breath sounds on the affected side. Tracheal deviation-- which means the trachea is shoved to the unaffected side. There are also temporary measures that can be done until a chest tube can be placed-- like sticking a needle in the chest. Then she could have figured out what she needed to fashion a chest tube.

Often times, when I spend time interviewing an expert, I have always come up with a better scenario, and a more realistic one than what I imagined would be good.
  

Medical Critique: CBS Drama Hostages 1/2

As you know, I'm critically watching some of the new Fall TV shows for medical accuracy. I've already posted about the CBS drama Hostages. You can find that here.

This week, I'm going to knock it down but then offer it a helping hand back up. Episode 5 is going to be the brief knock down.

If you haven't watched all the episodes you have been thusly warned that there will be spoilers in this post.

If you're not familiar with the show, the President needs an operation and his surgeon, played by Toni Collette, and her family have been taken hostage to force her hand to assassinate him or her family will be killed.

In episode five, the family plots to escape. They end up getting split up. The husband at home. The children on a bus to Canada and Ellen (Toni's character) almost getting on the bus until she sees video of her husband being shot in the gut.

And, of course, even though he's a cheating slime ball she goes home to save his life.

Issue One: One of the ways a person who has been shot and is bleeding dies is of exsanguination-- meaning all their blood leaks out. The reason significant blood loss kills you is that your body is no longer delivering oxygen and you go into shock/circulatory collapse. What you really need is BLOOD to save your life. Without it-- nothing the medical team can do will pull you out from the drain you're swiftly traveling down. When our trusty surgeon arrives home she finds her husband unconscious and not breathing . . . no pulse.

She starts CPR-- yea!! Then asks Mr. Hostage taker to get her medical bag from which she happens to have a hospital grade defebrillator.

Issue Two: There are only a few shockable rhythms. I've blogged about the use of electricity here. A likely rhythm for the patient to be in strictly from blood loss is what we call PEA or pulseless electrical activity. There is actually two parts of good heart activity. The electrical component and mechanical component. You need both working appropriately to propel your blood forward and keep you alive. You can actually have normal electrical activity and yet the heart is not mechanically beating-- thus the term pulseless electrical activity.

In the case of this character's husband-- his heart likely has normal electrical activity but since he's lost so much blood-- it doesn't have blood filling the chambers and so doesn't have anything to pump out. Hence the lack of a pulse.

I'm guessing this husband's injuries would lead to this set-up. Normal electrical activity with no pulse. So he doesn't need electricity. He needs BLOOD.

Issue Three: I don't know any physician anywhere that has a hospital grade defibrillator for their private use. Or would know how to work it . . . quickly. Now, this isn't a backhanded slap to my physician co-workers. They know how to do their job very well. This just isn't necessarily in their skill set. Nurses usually set-up the defribillator. The physician orders the desired amount of electricity.

I've taught advanced resusitation courses for two decades and I can tell you, across the board, every type of physician struggles to get it programmed. These classes are not a requirement for EVERY physician to take either.

So-- wrong treatment with too much ease of use.

What would have been more believable would have been for her to have an AED (automatic external defibrillator) in the home. These are designed for lay people to use and some people do actually have them for home use. They basically diagnose the shockable rhythms and provide electricity if indicated. It's what many first responders are carrying to even high school settings. They are very user friendly.

Check out my post on Thursday where I'll continue my discussion of this particular episode.

Up and Coming

Hello Redwood's Fans!

How's it going? It's been a few short weeks since I wrote the Sunday post. Just what have I been up to?

Traveling . . .

And I went to Disney!

I  saw the BIGGEST bats of my entire life. If these things come after me there will be some (okay a lot) of screaming involved. I'm just sayin'.

 It's always nice to see the Super Heroes out and about. Couldn't quite figure out what Spidey was doing but he did look quite fashionable on the motorized tricycle.

What adventures have you been up to?

This week I'm back to medical mayhem and analyzing the CBS drama Hostages.

A lot of good stuff to talk about.

Have a GREAT week!!

Should the Blacklist be Blacklisted?

This week I'm analyzing some of the new Fall TV shows-- medically speaking.

I've always been a fan of James Spader. No one does evil genius as good as he does.

The Blacklist is set up similarly to Hannibal (the first Anthony Hopkins movie) in the sense that he is a criminal mastermind and for some reason, as yet undiscovered, is only willing to talk with an FBI ingenue about criminal plots that he is aware of.

In one of the early episodes, the two attend a fund-raising event for a human rights advocate who is being targeted for murder. It just so happens that she's really trafficking humans and thus perhaps is justly murdered to prevent her from continuing this criminal enterprise. Of course, the young FBI agent is a big fan of this woman and has written papers about her humanitarian efforts.

When the trafficker's secret is exposed, James Spader's characters says:

"She's been given a lethal cocktail of the same barbiturates she used to drug her children. I have the antitode."

Then the FBI agent proceeds to do the pen to the trachea maneuver to help her breathe.

And my eye-rolling begins.

First of all-- what are the barbiturates? These would be drugs like amytal sodium (AKA a supposed truth serum drug), phenobarbital and Seconal. Oh, by the way, there is not an "antidote" for this type of overdose. There are only two antidotes for overdoses and they are Narcan for opiates and Flumazenil for Benzodiazepines (like Valium).

The purpose of an emergency tracheotomy (the pen to the throat for breathing) is to bypass an upper airway obstruction. The effects of an OD of barbiturates is a decrease in breathing or breathing cessation but the airway is not obstructed. To "save" this patient-- all our trusty FBI agent needed to do was give her mouth to mouth and all that extra blood could have been avoided.

You can read more about Barbiturate OD here. 

Fall TV Medical Analysis: Hostages

Obviously, you know I'm a stickler for medical accuracy-- hence the mission of this blog.

Fall TV has started and given me some new shows to analyze. Don't worry, I'm sure I'll comment every now and then on a few of my TV staples like Grey's Anatomy.

Just remember-- what you see on TV is not likely accurate. Maybe not even close.

Hostages, which is airing on CBS, actually has a pretty genius medical set-up. The president needs surgery (some type of lung surgery) and wants to increase popularity points by using a "public" doctor who happens to also be a woman.

For some nefarious reason not yet discovered-- there are people who want the president deceased. So as a means to this end they hold the doctor and her family hostage until she offs the president during surgery.

Of course, each family member has a secret they're hiding (except maybe the doctor) which all spills out when they're in crisis.

The first couple of episodes deal with how the good doctor, played by Toni Collette, saves the president's life by giving him a complication that will postpone the surgery.

What it shows is her leaving a vial of saline at his bedside. It comes out later that the president was accidentally given Heparin (which is a blood thinner) by a nurse starting his IV and the doctor suspected this when he had some bleeding at his IV site.

And-- surgery postponed.

Medically, I have a couple of problems with the scene. The vial the doctor left on the bedside table was sealed-- it's plastic top in place. These can't be screwed on and off. Once they are popped off, any good nurse assumes that the vial has been used in some way. These can be multiple dose vials (meaning many doses drawn up for different patients) but these days most hospitals used pre-filled syringes or one vial/patient. That particular vial that she left couldn't have been tampered with because the top was still in place.

I think what would have been more believable would be to show the doctor adding the medication to the vial, and leaving it opened at the bedside and then giving it to the nurse for the IV start versus just hoping the nurse uses it because it's there.

Also-- thinning blood based on one Heparin bolus isn't that easy to do. Generally a patient is given a bolus and then started on a drip for a period of time.

I do like the show and I'll keep watching. We'll see how the medical scenario plays out.

Author Question: Delivering Bad News

John Asks:

I'm killing off the husband of a wife. He's had a car accident and will die in the ER. His jeep was T-boned, rolled, and he was thrown out of the vehicle into oncoming traffic. The first vehicle rolled over his legs. She's been called to the ER. Can you point me to a good write-up of what would go on in the ER for both him and his wife as she arrives? 

Jordyn Says:

I don't know of one specific source so I'm including some links to my blog that talk about care of the car accident victim.

http://jordynredwood.blogspot.com/2012/10/author-question-car-accident-injuries-12.html

http://jordynredwood.blogspot.com/2012/10/author-question-car-accident-injuries-22.html

http://jordynredwood.blogspot.com/2013/04/author-question-treatment-of-car.html

As far as the wife-- typically news of a patient's death is not given over the phone. We usually say something like, "My name is Jordyn and I'm the nurse taking care of Johnny. He was involved in a car accident and is critically ill and we need you to come to the hospital. Please take your time and drive safely and we'll talk more when you get here."

When the spouse arrives they are usually taken to a small family room where the attending physician and likely the nurse (or some other person who can care for the spouse so the physician can leave) delivers the bad news. We don't use phrases like passed on, gone home, or lost the battle. It usually goes something like-- "Johnny was involved in a serious car accident. Despite our best efforts your husband died from his injuries."

The first part should be short and to the point because families don't hear much after you tell them that their loved one has died. Then we'll usually take the family's lead and let them ask whatever questions they need to.

Usually there is some prepping of the body so it's as presentable as possible. However, if the patient is going to be a coroner's case then all lines and tubes must be left in place. This is explained to the family as well as to what they'll see when they get into the room.

"I'm going to take you to see Johnny now. Just so you're aware he has a tube still left in his mouth and nose and several IV's in place. His face is very bruised from the car accident and his left arm is deformed from a broken bone."

Something along those lines. Even if the patient hasn't died-- we do try and prep the family for what they will see.

Families are given as much time as they want to be with the patient. If the ED is CRAZY busy and we absolutely need the room, arrangements might be made for the patient to go to a med/surg room to give the family more time with the body. It would mean needing to move the patient out of the ER for this and would be very rare. 

Author Question: Car Accidents, Head Injuries and Strokes Oh My!

Holly asks:

Got a question. Ok....let me try to make this simple. Charlie sees a doctor for some dizzy spells about a month prior to his accident, but doesn't go for further tests. He needs orthopedic surgery for broken bones after the accident. Would they do the surgery?

Jordyn: I don’t see this as a big reason NOT to do the surgery. Dizzy spells are pretty non-specific meaning LOTS of things benign (like I have extra fluid in one ear) to major (I have a brain tumor) can cause this. Most often times it is something very benign and transitory.  

Holly: And if he hit his head when his truck rolled over, would he HAVE to have a head injury?

Jordyn: No, he wouldn’t have to have a head injury in the sense that he wouldn’t have to have concussion. He likely would have some bruising and pain at the site of impact but head injury is denoted more by global headache (my whole head hurts and not just the bump), loss of consciousness, nausea/vomiting, confusion, and perhaps amnesia progressing to more serious things if you choose.  

Holly: I'm setting up a scenario where the insurance wants to deny coverage because of a pre-existing condition. (the dizzy spells maybe caused a stroke, or so they determine.)

Jordyn: I don’t think a complaint of dizzy spells would be enough for this. It’s not really a pre-existing condition. A pre-existing condition has to be an actual medical diagnosis and dizziness is a symptom—something only the patient can tell us they experience. A symptom is not something we can measure. So, if he had a diagnosis of TIAs or Transient Ischemic Attacks and one of his symptoms was dizziness then this might be more believable.

Holly: Which gives me a new question. Can you prove a stroke has happened? Or a mini stroke.

Jordyn: Yes, strokes (new and old) can appear on certain imaging tests. MRI is more specific for old and new brain injuries caused by stroke.

Up and Coming

How is everyone doing? Are you starting to gear up for the holidays? I am sad to see the autumn colors leaving us already. It seems like we just got out of snowy season (because our last storm was in May) and we are soon to see the snow again. The weather peeps are predicting lots of shoveling for hubby this winter.

For you this week:

It's author question week. As you know-- these are some of my favorite posts to write.

Tuesday: Holly poses a question about insurance and pre-existing conditions.

Thursday: John asks how we break the sad news of a patient's death to the family.

Hope you guys have a great week!

Jordyn